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Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods.

Patel AL, Trivedi S, Bhandari NP, Ruf A, Scala CM, Witowitch G, Chen Y, Renschen C, Meier PP, Silvestri JM - J Perinatol (2014)

Bottom Line: The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU.

View Article: PubMed Central - PubMed

Affiliation: Section of Neonatology, Rush University Medical Center, Chicago, IL, USA.

ABSTRACT

Objective: Owing to a rise in necrotizing enterocolitis (NEC, stage ⩾ 2) among very low birth weight (VLBW, birth weight <1500 g) infants from 4% in 2005 to 2006 to 10% in 2007 to 2008, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants.

Study design: In September 2009, we developed an NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ⩾ 2. In May 2010, we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).

Result: The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%) but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.

Conclusion: QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.

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Related in: MedlinePlus

Control chart (p-chart) presenting the proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). Major QI initiatives were implemented in December 2009 and June 2010 as delineated by the dotted lines. The solid black lines represent the monthly observed proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). The solid grey lines represent the center line or the mean proportion of infants that developed NEC stage 2 or 3 or surgical NEC for each phase. The dashed grey lines represent the upper control limits (UCL), corresponding to 3SD from the mean. The lower control limits are at 0. A downward trend (6 consecutive data points below center line) in NEC (A) and a significant shift (8 consecutive points below the center line) in surgical NEC (B) were observed in QI phase 2; however, a special cause variation (above the UCL) was noted in October 2011 for surgical NEC. Tests were performed with unequal sample sizes.NEC, necrotizing enterocolitis; QI, Quality improvement; UCL, upper confidence limit.
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Figure 2: Control chart (p-chart) presenting the proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). Major QI initiatives were implemented in December 2009 and June 2010 as delineated by the dotted lines. The solid black lines represent the monthly observed proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). The solid grey lines represent the center line or the mean proportion of infants that developed NEC stage 2 or 3 or surgical NEC for each phase. The dashed grey lines represent the upper control limits (UCL), corresponding to 3SD from the mean. The lower control limits are at 0. A downward trend (6 consecutive data points below center line) in NEC (A) and a significant shift (8 consecutive points below the center line) in surgical NEC (B) were observed in QI phase 2; however, a special cause variation (above the UCL) was noted in October 2011 for surgical NEC. Tests were performed with unequal sample sizes.NEC, necrotizing enterocolitis; QI, Quality improvement; UCL, upper confidence limit.

Mentions: No decrease in NEC or surgical NEC was noted between the baseline period and after QI phase 1 (implementation of the feeding protocol), whereas a sharp decline in NEC incidence was noted after addition of the NG tube handling changes in QI phase 2 (Table 2 and Figure 2). The rate of surgical NEC cases progressively declined from 5% in the Baseline phase to 4.8% in QI phase 1 to 1.2% in QI phase 2. Multivariable logistic regression analysis controlling for potentially confounding factors associated with NEC in bivariate analyses (birth weight, sex, race/ethnicity, antenatal antibiotics) demonstrated a significant effect of QI phase on NEC (OR 0.46, 95%CI 0.31-0.68, p<.001). Other statistically significant factors that predicted NEC in the final model included male sex (OR 2.85, 95%CI 1.48-5.50, p=.002), birth weight (OR 0.999, 95%CI 0.998-1, p=.046) and receipt of antenatal antibiotics (OR 2.01, 95%CI 1.08-3.96, p=.028).


Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods.

Patel AL, Trivedi S, Bhandari NP, Ruf A, Scala CM, Witowitch G, Chen Y, Renschen C, Meier PP, Silvestri JM - J Perinatol (2014)

Control chart (p-chart) presenting the proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). Major QI initiatives were implemented in December 2009 and June 2010 as delineated by the dotted lines. The solid black lines represent the monthly observed proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). The solid grey lines represent the center line or the mean proportion of infants that developed NEC stage 2 or 3 or surgical NEC for each phase. The dashed grey lines represent the upper control limits (UCL), corresponding to 3SD from the mean. The lower control limits are at 0. A downward trend (6 consecutive data points below center line) in NEC (A) and a significant shift (8 consecutive points below the center line) in surgical NEC (B) were observed in QI phase 2; however, a special cause variation (above the UCL) was noted in October 2011 for surgical NEC. Tests were performed with unequal sample sizes.NEC, necrotizing enterocolitis; QI, Quality improvement; UCL, upper confidence limit.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4216600&req=5

Figure 2: Control chart (p-chart) presenting the proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). Major QI initiatives were implemented in December 2009 and June 2010 as delineated by the dotted lines. The solid black lines represent the monthly observed proportion of VLBW infants that developed NEC stage 2 or 3 (A) and surgical NEC (B). The solid grey lines represent the center line or the mean proportion of infants that developed NEC stage 2 or 3 or surgical NEC for each phase. The dashed grey lines represent the upper control limits (UCL), corresponding to 3SD from the mean. The lower control limits are at 0. A downward trend (6 consecutive data points below center line) in NEC (A) and a significant shift (8 consecutive points below the center line) in surgical NEC (B) were observed in QI phase 2; however, a special cause variation (above the UCL) was noted in October 2011 for surgical NEC. Tests were performed with unequal sample sizes.NEC, necrotizing enterocolitis; QI, Quality improvement; UCL, upper confidence limit.
Mentions: No decrease in NEC or surgical NEC was noted between the baseline period and after QI phase 1 (implementation of the feeding protocol), whereas a sharp decline in NEC incidence was noted after addition of the NG tube handling changes in QI phase 2 (Table 2 and Figure 2). The rate of surgical NEC cases progressively declined from 5% in the Baseline phase to 4.8% in QI phase 1 to 1.2% in QI phase 2. Multivariable logistic regression analysis controlling for potentially confounding factors associated with NEC in bivariate analyses (birth weight, sex, race/ethnicity, antenatal antibiotics) demonstrated a significant effect of QI phase on NEC (OR 0.46, 95%CI 0.31-0.68, p<.001). Other statistically significant factors that predicted NEC in the final model included male sex (OR 2.85, 95%CI 1.48-5.50, p=.002), birth weight (OR 0.999, 95%CI 0.998-1, p=.046) and receipt of antenatal antibiotics (OR 2.01, 95%CI 1.08-3.96, p=.028).

Bottom Line: The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU.

View Article: PubMed Central - PubMed

Affiliation: Section of Neonatology, Rush University Medical Center, Chicago, IL, USA.

ABSTRACT

Objective: Owing to a rise in necrotizing enterocolitis (NEC, stage ⩾ 2) among very low birth weight (VLBW, birth weight <1500 g) infants from 4% in 2005 to 2006 to 10% in 2007 to 2008, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants.

Study design: In September 2009, we developed an NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ⩾ 2. In May 2010, we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).

Result: The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%) but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.

Conclusion: QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.

Show MeSH
Related in: MedlinePlus